BROOKS COLLEGE of HEALTH SCHOOL of NURSING Adult Health Lecture Anesthesia : Concepts in Practice...
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Transcript of BROOKS COLLEGE of HEALTH SCHOOL of NURSING Adult Health Lecture Anesthesia : Concepts in Practice...
![Page 1: BROOKS COLLEGE of HEALTH SCHOOL of NURSING Adult Health Lecture Anesthesia : Concepts in Practice Tammy Carroll, MSN, CRNA, ARNP Assistant Program Director/Instructor.](https://reader034.fdocuments.in/reader034/viewer/2022051516/56649e165503460f94b01464/html5/thumbnails/1.jpg)
BROOKS COLLEGE of HEALTH SCHOOL of NURSING
Adult Health Lecture Adult Health Lecture Anesthesia : Concepts in PracticeAnesthesia : Concepts in Practice
Tammy Carroll, MSN, CRNA, ARNP Tammy Carroll, MSN, CRNA, ARNP Assistant Program Director/InstructorAssistant Program Director/InstructorNurse Anesthetist ProgramNurse Anesthetist Program
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Objectives
• Basic Concepts in Anesthesia• Rationales for Choice of Anesthetic Technique • Discuss Surgical Risks• Differentiate: General, Regional and MAC/Local
Anesthetic– Disadvantages– Advantages
• Discuss surgical position and related risks• Identify Perioperative Complications
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Basic Concepts
• Anesthesia – Nursing Specialty – Advanced Practice (ARNP-CRNA)– MSN (DNP)– Science & Art – Highly technical • Skills• Knowledge base
– Critical Care Experience – Professionalism
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Basic ConceptsSubspecialties
in the Practice of Anesthesia
– Cardiothoracic– Critical Care– Neuroanesthesia – OB
•Pain Management•Pediatric•Ambulatory
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Basic Concepts
Anesthesia
‘induced state of partial or total loss of sensation, occurring with or without loss of consciousness’
– Utilization of drugs and/or inhalation agents– Resulting in an insensibility to pain
Ignatavicius, Donna D.. Ignatavicius, Donna D.. Medical-Surgical Nursing: Critical Thinking for Medical-Surgical Nursing: Critical Thinking for Collaborative Care, Single Volume, 5th EditionCollaborative Care, Single Volume, 5th Edition. Saunders Book Company, . Saunders Book Company, 042005. 21.2.3. 042005. 21.2.3. <vbk:0-7216-0446-3#outline(21.2.3)><vbk:0-7216-0446-3#outline(21.2.3)>
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Basic Concepts
• Anesthesia Techniques– General– Regional– Peripheral nerve blocks– MAC/Local
– Local only**
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Rationale of Anesthetic Choice
• The Procedure• The Surgeon/Anesthesia Provider • The Patient– Preference– Medical History– Surgical History– Assessment
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Rationale of Anesthetic Choice
• Degree of Risk: Anesthesia for surgical procedures:
– Major (CABG)– Minor (Cataract)
– Emergent (Appy,Trauma)– Urgent (Cholecysectomy)– Elective (Plastics, hernias)
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Rationale of Anesthetic Choice
• Purpose for surgical procedures: :– Diagnostic – Cosmetic – Ablative– Transplant– Palliative– Constructive– Reconstructive/Restoration – Procurement
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Rationale of Anesthetic Choice
• Can this procedure be accomplished without going to sleep?– Type and duration– Pain – Muscle Relaxation– Length of procedure
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Rationales: Surgeon and Anesthesia Provider
• Preference/Ability– Attitude– Skill– Patience!
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Rationale for Choice: Patient
• Preference• History– Airway– Previous anesthetic experience– Coexisting Diseases & severity
• Present condition• Assessment
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Rationale for Choice: Patient
• Medical conditionsAirway• Difficult or Prolonged intubations • Cervical Spine• Neck radiation, tumor• OSA• Rheumatoid arthritis• Morbid Obesity
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Rationale for Choice: Patient
• Medical conditionsGenetics • Down Syndrome• Pierre Robin Syndrome • Malignant Hyperthermia • Atypical pseudocholinesterase
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Rationale for Choice: Patient• Medical conditions
Cardiovascular• Exercise Intolerance• HTN• CHF• CAD• Valvular Disease • Cardiomyopathy• Angina• PVD• Dysrhythmia
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Rationale for Choice: Patient
• Medical conditionsPulmonary• Asthma• TB• URI• Dyspnea on Exertion
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Rationale for Choice: Patient
• Medical conditions– Medical History
Endocrine• Diabetes• Hyperthyroid• Pheochromocytoma• Steroid dependency
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Rationale for Choice: Patient
• Medical conditions– Medical History
Neurologic• Carotid Artery Disease• CVA/TIA• Seizure• Chronic Pain • Motor/Sensory Loss
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Take Home: Technique Choice• Summary
– Preference of the patient, anesthesia provider and surgeon
– Coexisting diseases that may or may not be related to the reason for surgery (GERDS, DM, asthma)
– Patient age – Suspected difficult airway management and
tracheal intubation – Elective or emergency surgery
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Basic Concepts: Technique Choice• Summary, cont.
– Duration of surgery or procedure– Site of surgery – Body position of the patient during surgery – Likelihood of increased amounts of gastric
contents at the time of induction of anesthesia
– Anticipated recovery time – Postanesthesia care unit discharge criteria
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Anesthetic Choice & Patient Risks
• Informed Consent!
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Rationales for Anesthesia Technique: Questions
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Basic Concepts
• Anesthesia
• General• Regional • MAC/Local
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Anesthesia Techniques: Terms
• Preparation– Patient– OR
• Preinduction • Induction• Intraoperative management• Emergence • Postoperative management
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Anesthesia Techniques: Concepts
• Management of Airway– Spontaneous– ETT – LMA– Mask
• Maintain anesthetic level– Inhalation Agent – IV Drugs
• Maintain Patient Hemodynamics– Anesthetist!
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Differentiating AnesthesiaTechniques
• General Anesthesia: To Sleep!– All of the body
‘…a reversible depression of the CNS sufficient to permit surgery to be performed without movement, obvious distress, or recall’ (Evers)
i.e. Cardiothoracic, intracranial, upper abdominal (movement)
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Differentiating Anesthesia Techniques General Anesthesia: Goals
• Analgesia: lack of pain• Anesthesia: lack of sensation• Amnesia: lack of memory (immediate perioperative
events) • Areflexia: lack of reflexes • Anxiolysis: lack of anxiety • Antiemesis: lack of emesis• Muscle relaxation• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
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Differentiating AnesthesiaTechniques
• Regional: To Sleep, or not!– Part of the body by region/area
SpinalEpiduralPeripheral blockWith/without sedation
i.e. Amputation, L & D, carpal tunnel repair
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Differentiating Anesthesia Techniques Regional Anesthesia: Goals
• Analgesia: lack of pain• Anesthesia: lack of sensation• Amnesia: lack of memory (immediate perioperative
events) **• Areflexia: lack of reflexes • Anxiolysis: lack of anxiety** • Antiemesis: lack of emesis• Muscle relaxation• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
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Differentiating AnesthesiaTechniques
• MAC/Local: To Sleep, or not!– Specific area of the body
Peripheral blockLocal Anesthetic to surgical site With/without sedation
i.e. Amputation (toe), carpal tunnel repair, breast biopsy, AV Fistula, Eye surgeries, small plastics, hernia repair
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Differentiating Anesthesia Techniques MAC/Local Anesthesia: Goals
• Analgesia: lack of pain• Anesthesia: lack of sensation• Amnesia: lack of memory (immediate perioperative
events) ** • Anxiolysis: lack of anxiety** • Antiemesis: lack of emesis• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
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General Anesthesia Advantages/Disadvantages
– More risks• Circulatory depression• Respiratory depression• CV response to ETT • Laryngospasms/
Bronchospasms• Dental/soft tissue
damage• Aspiration
– Postop complications– More drugs– Postop N/V
• Most Controlled• Any age• Any procedure• Less risk of awareness• Less risk of patient
movement• Rapid Reversal
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Regional Anesthesia Advantages/Disadvantages
• Requires more skill• Is not appropriate for all
procedures or patients• May result in higher levels of
anxiety• May result in longer recovery
time• Awake patient• Hypotension• PDPH• Infection at site
• Airway & Gag Intact• Less respiratory and cardiac
depression• Fewer systemic drugs• High risk of awareness• Decreased Postop N/V• Increased postop pain relief
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MAC/Local Anesthesia Advantages/Disadvantages
• Requires more skill• Is not appropriate for all
procedures or patients• May result in higher levels of
anxiety• Awake patient• May result in intraop
conversion
• Less respiratory and cardiac depression
• Fewer systemic drugs• High risk of awareness• Decreased Postop N/V• Increased postop pain relief• May result in shorter
recovery time
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Anesthesia
• Pharmacology Adjuncts– Preop• Reduce Anxiety (benzodiapines)• Reduce risk of aspiration (H2 blocker, prokinetic, 5HT3,
anticholinergic• Reduce Pain (narcotic)
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Anesthesia
• Pharmacology Adjuncts– Intraop• Induction
– Oxygen– Blunt CV response to ETT (lidocaine)– Induction Agents (propofol, etomidate, Ketamine, sodium
pentothal)
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Anesthesia
• Pharmacology Adjuncts– Intraop
• Intubation Agents (DMR, NDMR)» Succincylcholine» Zemuron, Vecuronium, Nimbex
• Maintenance (Inhalation/IV)» 02, Isoflurane, Sevoflurane, Desflurane, N2O
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Anesthesia
• Pharmacology Adjuncts– Emergence• Reversal
– MR
• Pain• Postop N/V
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GA, Regional, MAC/Local: Questions
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Positioning the Surgical Patient
All positioning schemes have 3 goals:1. Maximum exposure to the surgical area while
maintaining homeostasis and preventing injury2. Position must provide the Anesthetist with
adequate access to the patient for airway management, ventilation, medications, and monitoring
3. Promote the enhancement of a satisfactory surgical result
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Positioning the Surgical Patient
• Positioning and Anesthesia– Blunted or obtunded reflexes prevent patients from
repositioning themselves for comfort– Anesthesia may blunt compensatory sympathetic nervous
system reflexes that would minimize systemic BP changes with abrupt position changes
– Rendering patients unconscious and relaxed may permit placement in position they may not have normally tolerated in an awake state
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Positioning the Surgical Patient
Preexisting patient attributes associated with increased incidence of perioperative neuropathies:– extremes of age or body weight, – preexisting neurologic symptoms, – diabetes mellitus, – peripheral vascular disease,– alcohol dependency, – smoking, – and arthritis.
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Positioning the Surgical PatientPositioning the Surgical Patient
• 1999 - 670 claims for anesthesia-related nerve injuries
• #1 - Ulnar nerve (28%)• #2 - Brachial plexus (20%)• #3 - Common peroneal (13%)
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Positioning the Surgical Patient
Ulnar nerve injury• Caused by arms along side patient in pronation• Ulnar nerve compressed at elbow between table
and medial epicondyle.• Prevented by positioning arms in supination.• Hypotension and hypoperfuison increase risk.
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Positioning the Surgical PatientBrachial Plexus
• Abduct arms to no more than 90 degrees.• Minimize simultaneous abduction, external arm
rotation, and opposite lateral head rotation.• In prone position, maintain abduction and anterior
flexion of arms above head to no more than 90 degrees.
• In lateral position, place chest roll under lateral thorax to minimize compression of humerus into axilla.
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Positioning the Surgical Patient
Peroneal nerve
• Caused by direct pressure on the nerve with the legs in lithotomy position.
• Nerve compressed against neck of fibula.• Prevented by adequate padding of lithotomy
poles.
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Positioning the Surgical Patient
• Positons which require special care:– Prone– Lateral– Lithotomy– Sitting
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Positioning the Surgical Patient• Most are nerve injuries due to overstretching and/or
compression.• 90% undergo complete recovery.• 10% are left with residual weakness or sensory loss.• Many injuries can produce lasting disability.• Many injuries lead to litigation.• General anesthesia removes many of the bodies natural
protective mechanisms.• Recognition of risks and prevention is essential.
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Positioning Checklist
• Head, neck and cervical spine supported in a straight line.• Scalp, head, and face protected from tight anesthesia
mask/straps.• Ears protected from traumatic pressure/objects.• Chest and torso kept in physiological position for adequate
full, bilateral respiratory exchange and expansion.• Breasts & genitalia protected from excessive pressure.
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Positioning Checklist• Arms in physiological position and supported.
- not to exceed 90 degree extension at shoulder- in flexion not hyperextension- upper arm not hanging over edge of table or
rubbing on metal part of table- elbow area protected from ulnar pressure- hands free of pressure and compression- fingers in slight flexion or neutral extension- wrist restraints loose or padded- palms up on armboard- palms towards body when arms at side
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Positioning Checklist• Genitals free of trauma, pressure, or rubbing.• Back in physiological position, spine in straight line
- slight sacral curvature- soft small positioning devices under sacral area and knees
to relieve pressure, pain, or stretching.• Thighs/legs in straight line of flexed position; no pressure to iliac
crests, greater trochanters, area bt back & knees, peroneal nerve on lateral aspects of knees, or to patellas.
• Heels/ankles/toes free of pressure or rubbing trauma.• Safety belt placed snugly over patient w/blanket or towel between
strap and patient’s body to prevent maceration.• Other straps or positioning devices placed only over padded body
parts.
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Perioperative Complications
• Minor to Major– Sore throat– Teeth,soft tissue injury– Bleeding– Hemodynamic instability – Stroke– MI– Death
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Perioperative Complications
• Uncommon- but Major– Malignant Hyperthermia
• Acute, life threatening• Volatile anesthestics/Succinylcholine exposure• s/s
– Tachycardia– Dysrhythmias– Muscle rigidity– Hypotension– Tachypnea– Skin mottling– Cyanosis– Myoglobinuria
– ETCO2, temperature
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MH: Treatment
• Diagnose Early!• Stop the trigger• Lots of staff• Dantrolene• Ice• IV fluids• Treat arrhythmias
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References
Nagelhout, J., Zaganiczny, K. Nurse Anesthesia. Stoelting, R.K., Miller, R.D. Basics of Anesthesia. Fleisher, L.A. Anesthesia and Uncommon Diseases. Ignatavicius, Donna D.. Medical-Surgical Nursing:
Critical Thinking for Collaborative Care, Single Volume, 5th Edition. Saunders Book Company, 042005. 21.2.3.
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Questions